Failure to Follow Physician Orders for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow physician's orders regarding the application of hand splints for a resident diagnosed with multiple muscle contractures and severe cognitive impairment. The physician's orders and care plan specified that a left-hand orthotic should be applied with bedtime care and removed with morning care, with skin checks before and after application. Observations revealed that the resident was not wearing the left-hand splint as ordered, and the splint was found in a bedside basket instead. Documentation and interviews indicated that nurse aides and charge nurses did not consistently document or verify the application of splints, and the electronic charting system did not include splint assignments for the resident or others. Further investigation showed that the nurse aide responsible for the resident did not indicate the need for splints in the assignment roster or electronic documentation, and the charge nurse's documentation for the overnight shift made no mention of the splint. Interviews with staff confirmed that the splint was not applied as ordered during the relevant shift, and the facility's policy required splints to be applied per physician orders. The lack of proper documentation and communication among staff led to the failure to ensure the resident received the prescribed care to maintain or improve range of motion.